Provider Demographics
NPI:1770591182
Name:TAKLA, VICTOR N (MD)
Entity type:Individual
Prefix:DR
First Name:VICTOR
Middle Name:N
Last Name:TAKLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:4136 NW THUNDER CREST RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-8028
Mailing Address - Country:US
Mailing Address - Phone:208-667-6511
Mailing Address - Fax:208-666-1642
Practice Address - Street 1:1015 NW 22ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3025
Practice Address - Country:US
Practice Address - Phone:208-667-6511
Practice Address - Fax:208-666-1642
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD15896207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR050043869OtherRR MEDICARE
CAXPY194606Medicaid
OR043802Medicaid
WA1160456Medicaid
WA1160456Medicaid
OR050043869OtherRR MEDICARE